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Earl Howe: I rise to speak to Amendment No. 15, which stands in my name. The amendment is identical in spirit to Amendment No. 12, to which the noble Lord, Lord Clement-Jones, has just spoken, although, with all respect to him, the wording of that amendment reads a little oddly as it suggests that the relevant home-based healthcare is provided in the home of the nurse or doctor, which of course is not the case.

I wish to re-emphasise a key point. Healthcare provided at home is becoming increasingly common. I refer not just to day-to-day nursing care but to often highly intensive and sophisticated medical procedures. The care of people in their own homes rather than in a hospital or a nursing home is to be welcomed. I believe that the Government are in agreement with that. The Bill should reflect current developments in healthcare. I urge the Minister to consider this issue with particular care.

A point closely allied to that is the need to regulate healthcare assistants engaged in delivering healthcare at home. I shall talk more about healthcare assistants when we reach a later group of amendments. Suffice it now to say that if both they and the work that they are doing for people in a domestic setting are unregulated, that runs directly counter to the theme of the Bill.

Lord Jenkin of Roding: I suggest that these are amendments to which the Government will wish to give a good deal of thought. I referred earlier to the Forest Healthcare Trust, of which I used to be chairman. The trust ran a hospital-at-home service. Such services are becoming more and more common as a way of relieving the pressure on beds within hospitals and in many cases giving patients a very much better service in the familiar surroundings of their own homes. In fact our experience was that they received a much better service in the hospital-at-home.

I remember one dreadful case. I need not go into the details but it was the only case where I felt it right, as chairman of the trust, to sit through the whole of the coroner's hearing on the patient, who had in due course died. There had been rather deplorable treatment in the hospital, amounting to quite serious neglect. The patient was sent home to a hospital-at-home and the nurses immediately recognised what had gone wrong. The family said that under no circumstances did they want the patient to go back to hospital, but the person actually died of other causes.

The hospital-at-home is becoming a valuable service, but it needs to be effectively regulated. The example to which I referred came wholly under the NHS and therefore would come within the Minister's definition of "management". But it could equally well have been a

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service which the trust had contracted out to a private concern. In those circumstances, regulation should be applied because it is not always the case that the trust contracting out will have the resources properly to assess the value and quality of the care being given. Exactly the same can happen with respite services.

There is also the question of psychiatric services. It is increasingly the case that psychiatric care is given to patients in their own homes. There has been a transition-- from doctors and nurses who have been used throughout their careers to a ward-based service in large psychiatric hospitals to a system of delivering psychiatric care in the patient's own home. Here again, if it is an NHS service, no doubt the NHS management and the CHI will provide a proper form of quality control. But if that service is contracted out--the Minister has already referred to the fact that a good deal of psychiatric services are now provided by independent concerns--it is all the more important that there should be effective regulation.

The noble Lord, Lord Clement-Jones, is on to a good point with at least some of these proposals. I hope that the Minister will take them away and examine them carefully. In a Bill that is supposed to bring the whole system under a single, common national standard of care, we do not want to find ourselves with any gaps.

Lord Rix: Before speaking to my Amendment No. 17 which is included in this grouping, perhaps I may say to the noble Lord, Lord Clement-Jones, that I hope, if he proceeds with Amendment No. 13, he will take the advice of his noble friend Lord Addington, so that the subsections appear in plain English and use one word instead of three.

Amendment No. 17 seeks to provide a definition of day services to allow for their inclusion within the standards, registration and inspection provisions contained in the Bill. I believe that it will be of some help to the Minister and his department.

One of the great strengths of this legislation is that it seeks to bring coherence to the hitherto unco-ordinated registration and inspection regimes, which are often not comprehensive. I believe that the Bill will bring greater co-ordination to the social care sector and that it goes a long way to making the system more comprehensive. But with the exclusion of day services, it simply does not go far enough.

At Second Reading, I cited the example of a day centre in Sheffield where physical and sexual abuse had gone undetected over many years. It is our responsibility to act upon the evidence. I do not believe that there is a palpable distinction between residential services and day care services in terms of vulnerability and risk; indeed major independent inquiries such as the Longcare abuse inquiry in Buckinghamshire have also recommended that inspections should be extended to day services. Adults with learning disabilities spend substantial proportions of their everyday lives in services which are not registered, not approved, not checked and not accountable. That

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state of affairs must change. I should welcome the Minister's assurance that the political will exists to effect that change.

Lord Laming: Perhaps I may make three brief points. First, respite care is a feature of many care establishments. It depends whether Clause 3 of the Bill as presently drafted incorporates both short and long-term care. If it incorporates both, it should incorporate respite care. If it is intended to convey only long-term care, the amendment proposed by the noble Lord, Lord Clement-Jones, seems essential. If I may say so with good grace, Amendment No. 15 seems to be an illustration of the difficulties that will remain throughout the Bill if Clause 2 stands.

As regards Amendment No. 17, I, too, am surprised that day services appear to have been excluded from the regulation and inspection system. The wording of Amendment No. 17 is extremely helpful.

Baroness Masham of Ilton: Perhaps I may add a word about those who live at home and have carers. I implore the Minister to do something about regulation of the agencies and possibly the carers. The situation is impossible at present. Charges are extraordinary. In some agencies there is no regulation at all. Some charge an amazing amount. Perhaps I may talk to the Minister outside the Chamber about this matter. We need to employ two, if not three, carers for my husband. Some agencies are exceedingly good; some are very dangerous. There are many vulnerable people living in their own homes under a tremendous amount of medication and getting into serious difficulties. There is no regulation as regards people who may be alcoholics coming in to work. So much needs to be done. But it is the expense of care in the home which causes problems. I hope that during the passage of the Bill we shall be able to do something about it. I have sent some information to one Minister regarding the regulation of care homes. The matter needs addressing. If, at this very moment, all the New Zealand, Australian and South African people went home, very vulnerable disabled people would have a real problem.

5.45 p.m.

Baroness O'Cathain: I note the comments of the noble Baroness, Lady Masham. I have some experience of the issue and support every single word she said. There are serious problems. For example, when I asked one carer who was sent into my home about her training, she said, "I used to work in an electronics factory. I happened to pass by the care agency last Saturday and the people there said, 'There's a lovely job going. Would you be prepared to do it?'" It was ludicrous. She had no idea at all of how to cope with a disabled person. There has to be some regulation.

Baroness Pitkeathley: That will be precisely the function of the general social care council, when it is set up. All those workers will be regulated and inspected.

Lord Hunt of Kings Heath: Perhaps I may turn first to Amendments Nos. 12 and 22 tabled by the noble

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Lord, Lord Clement-Jones. I am grateful to the noble Lord for explaining the purpose of his amendments. It was not entirely clear from the drafting, which, as it stands, could be taken to include general practitioner home visits and district nursing services.

I listened with great interest to the noble Lord's points about home-based care agencies and to the more general points raised about issues relating to private medical services undertaken in people's homes. Rather than say any more about the matter at this time, I should like to reflect on those issues without any commitment at this stage and take on board the comments made. No doubt we can debate the matter again on Report. Some important issues have been raised which require reflection.

Amendments Nos. 13 and 20 offer a definition of a "residential respite care establishment" and require such establishments to be registered. I am in full agreement that care homes which provide care on a short-term basis should be registered in the same way as care homes which provide people with permanent accommodation and care. It is certainly the intention that such respite centres should be registered with the national care standards commission, and the definition of "care home" in Clause 3 of the Bill is wide enough as it stands to cover that type of establishment.

The definition reads:

    "an establishment is a care home if it provides accommodation, together with nursing or personal care, for any of the following persons",

and subsection (2) lists those who will come under the provision. The word "accommodation" is not qualified in any way, so I assure noble Lords that it would cover accommodation for as little as one night only. In other words, any establishment which offers nursing or personal care overnight for the categories of persons listed in subsection (2) of Clause 3 will need to be registered as a care home. I hope that I have managed to reassure the Committee on that point.

Amendments Nos. 14 and 21 define a "close care sheltered housing establishment" as being an establishment which provides people who are ill, disabled, infirm or dependent on drugs or alcohol with accommodation together with personal care or nursing--but not board--and require such establishments to be registered.

In the Registered Homes Act 1984, a residential care home is defined as an establishment which provides accommodation together with both board and personal care for persons in need of it by reason of old age, disability, past or present dependence on drugs or alcohol or past or present mental disorder.

We are aware that this current definition is unsatisfactory. We know that there are establishments which provide accommodation and personal care for vulnerable people and which are to all intents and purposes residential care homes but which escape the requirement to register because they do not provide board. For example, they may make residents pay for their meals each day rather than include food in the overall contract price. We do not believe that that is acceptable. The Bill therefore offers a new definition of

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"care home" as an establishment which provides accommodation together with nursing or personal care only. There is no longer any mention of "board". Therefore, in future, even if board is not provided, such establishments will be required to register as care homes.

I turn to Amendments Nos. 14A and 22A which concern nurse agencies. Under our proposals nurse agencies will have a level playing field regulated by the same system as other employment agencies, including all those supplying other healthcare professionals under the Employment Agencies Act 1973. I have listened with care to the points raised. I believe that to suggest that nurses agencies should be registered and inspected in addition to complying with the provisions of the 1973 Act may be taken to imply that nurses are less professional than other healthcare professionals. I am sure that that is not the intention of the Committee. We shall ensure that should any additional safeguards be needed they will be put in place, for example, through codes of practice for employers. I am convinced that what we propose for nurses agencies will provide better protection for employers, the nurses engaged by agencies and vulnerable people while also minimising the regulatory burden on business. I hope that I have reassured noble Lords on that matter.

I turn to Amendment No. 15. The new regulatory framework for domiciliary care is designed specifically to include care that is of a personal and non-clinical nature. It is not our intention to confuse this with nursing or clinical tasks which involve a fundamentally different training and skill profile. We believe that that would distort the nature and purpose of the domiciliary care regime and stretch it so widely that it would lose its focus and impact. That focus is specific to the needs of domiciliary care which is essentially a sector with extremely low levels of training and qualifications. The domiciliary care regulation scheme will be a powerful driver to address that deficiency. On the other hand, nurses are highly qualified and registered professionals with professional responsibility for their own clinical practice. I do not believe that to extend domiciliary care regulation to nursing and clinical services is a helpful move.

I turn finally to Amendments Nos. 16, 17 and 19 which all deal with day care services. However, Amendment No. 17 has a wider definition than Amendment No. 16. I am conscious that there is disappointment that day care services are not included in the services to be regulated when the national care standards commission comes into force and starts its work. I hope the Committee accepts that that is in no way because of lack of concern for people with, say, learning disabilities, who are major users of such services, or the quality and standards of day care. It rests upon the practical question of what we can sensibly expect the commission to do when it takes on its considerable and very important responsibilities. In addition to its responsibility for the many thousands of care homes and other services which are already regulated, the commission will be given responsibility for regulating a number of new services not previously

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regulated. This represents a very significant extension of the scope of regulation. We believe that that is as much as we can expect it to deal with at the beginning of its life. We do not want to overload the commission. We believe that it must be allowed to concentrate on carrying out its new duties effectively. We shall, however, keep the remit of the commission under review.

Clause 39 allows the Secretary of State to extend the provisions of Part II to other social care services equivalent to those which may or must be provided by local authorities in the exercise of their social services functions. It may be that in time other services, such as day services, will be brought within the scope of regulation. Certainly, the inclusion of such a clause in the Bill means that we have day centres in mind as a likely example. We have said as much in the Explanatory Notes. Although the noble Lord, Lord Rix, may press me, I cannot at this stage give an absolute assurance as to when this may happen. We must be careful that we do not ask the national care standards commission to undertake an impossible task with the risk that it simply cannot cope and vulnerable people are put at risk.

Before I conclude, I note the different definitions of day care in the amendments. I believe that the wider definition of day services, which may include a number of dispersed services not attached to any particular facility and not specific to those who receive care, will present significant difficulties in terms of boundaries. Regulation must always be appropriate, targeted and proportional. But I have already had a very helpful discussion with the noble Lord, Lord Rix, about this matter. There may be workable ways to define the tasks. That is one of the issues that will need a great deal of work and consultation before the Government can use Clause 39 to add such services to be regulated by the commission. I hope that the noble Lord is assured as to the possibilities of including day care in the regulatory system and will therefore not press his amendment.

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